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Comment and Controversy

Single-payer system is the only option

September 2009 · Vol. 21, No. 09
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Thanks to Dr. Barbieri for pointing out that the Massachusetts insurance plan is not going to work on a national level. With insurance companies as we know them, $400 billion a year are necessary to simply administer the system. (And the average salary of a health-care insurance CEO is $15 million annually.) I say we take all this money and use it to pay for health care so that all of the uninsured can be covered. Simply gather money from taxpayers and pay it out to hospitals and doctors so that they can take care of everyone—especially the 10% of the population that uses 70% of health-care services. Now that’s an effective means of insurance!

The single-payer system is the only system that has a chance of rectifying our corrupt system, and a majority of doctors and the American public already recognize that fact.

George C. Denniston, MD, MPH
Seattle, Wash

Seeking clarification

What is the source of the 48 million figure cited in the headline of Dr. Barbieri’s editorial? It was given as the number of people who do not have health insurance, but was not referenced in the article.

Does that number include illegal aliens and non-US citizens?

Max Maizels, MD
Richmond, Va

Dr. Barbieri responds: Single-payer system would create a monopoly

I agree with Dr. Denniston that the health-insurance administrative bureaucracy creates unnecessary waste. Many commercial insurance companies have excessively high overhead and pay their executives outsized compensation packages. These wasted resources could be better used to provide health care.

In contrast, Medicare, one of the largest insurers in the United States, has a relatively low administrative overhead and pays physicians quickly after a bill for professional services is submitted. However, in general, Medicare pays physicians at relatively lower rates than commercial insurers.

A single-payer system will create an insurance monopoly. An insurance monopoly will likely result in a reduction in physician reimbursement. If a single-payer system were associated with a 30% reduction in physician reimbursement rates, would US physicians support the new insurance monopoly?

As Dr. Maizels’ question suggests, it is very difficult to precisely count the number of people without insurance residing in the United States. The US Census Bureau attempts to provide estimates of various key population statistics, including insured and uninsured US residents, on an annual basis. Its report is available at (click on “Health Insurance”). The report is based on a survey sample with statistical extrapolation to the entire US population.

How to treat migrant US residents for the purposes of this population survey is controversial. Some authorities recommend counting all US residents, regardless of their status, because they are likely to seek health care in the United States if they become sick. Other authorities would prefer to exclude migrants who are in the United States without proper documents from the estimate of uninsured residents.

Almost everyone agrees that the number of uninsured US residents is very high, whether it is 40 million, 45 million, or 50 million. Interestingly, based on the census surveys performed from 1992 to 2007, the percentage of uninsured US residents has remained steady at about 15% of the population.

Clearly, we have a big problem, and it is going to be very difficult to solve.

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